How the scare tactics of the past shape the Affordable Care Act debate today

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The Affordable Care Act has prompted a Supreme Court case, polarized Congress, and defined a national election. It has also inspired a secondary battle in the creative realm. Opponents of the law have produced videos in which a creepy-looking Uncle Sam prepares to administer a prostate exam; they’ve altered photos of the president to look like Heath Ledger’s sadistic Joker in “The Dark Knight.” Meanwhile, government agencies charged with enrolling people have responded with friendly animations that promote how the law works, while left-leaning groups have contributed zany pro-ACA ads in which recently insured college “bros” perform keg stands, worry free.

There’s a name for all of this, of course. The campaign to get people to embrace the Affordable Care Act, and the countervailing effort to cast doubt on it, is essentially a propaganda war. And though propaganda might seem like a heavy weapon to deploy on an already-passed health care law, public health has been the site of intense propaganda wars for more than a century—sometimes with lurid, dramatic imagery that makes the tussle over the ACA look tame.

You’ve definitely seen public health propaganda, even if you didn’t think of it in those terms: practice safe sex, buckle your seat belt (“click it or ticket”), stop smoking, don’t drink and drive. If these types of appeals feel less sinister than some propaganda from the past, that’s not an accident: It’s evidence of a meaningful shift in our awareness of propaganda, and what kind of messages work on us.

The kegstanding frat-bros.

Propaganda is nearly as old as human civilization, but scholars generally cite World War I as having given birth to the medium in its modern form. Governments on both sides of the fight exploited the rise of film, newsreels, and national periodicals that gave them access to a new mass audience. The result was often pretty blunt: In America, President Woodrow Wilson established the Committee on Public Information, which made a finger-pointing Uncle Sam a household figure, and disseminated over-the-top images that demonized the German Kaiser as a “mad brute” gorilla set on ransacking American virtue.

In “Propaganda: Power and Persuasion,” a new book adapted from a recent exhibition at the British Library by the same name, David Welch, director of the Centre for the Study of Propaganda, War and Society at the University of Kent, England, explains that following the war, governments put their new propaganda tools to work in the sphere of public health, which was increasingly viewed as a key part of what made countries strong.

The British Library

Health care campaigns from the early 20th century used the blunt tactics of wartime propaganda. Here, a giant fly threatened a child (Britain, c. 1920)

Josef Stalin saw rampant alcoholism as a threat to his Five-Year Plan in the 1920s and launched a propaganda campaign to get Soviets to quit drinking. A typical piece from the era shows a brawny worker holding a sledgehammer poised above a bottle of vodka. Other antialcoholism campaigns recognized that if men wouldn’t give up drinking for their country, maybe they would for their families. A 1918 poster from France shows a distressed mother with two children cowering behind her skirt, one hand covering her eyes in shame, and the other outstretched towards her lout of a husband, begging him to hand over his bottle of liquor.

As with the Affordable Care Act, sometimes public health campaigns inspired a propaganda backlash. In the early 1900s, smallpox outbreaks were common and devastating, and public health officials in the United States responded with compulsory vaccination laws and aggressive door-to-door vaccination drives. A grass-roots antivaccination movement in the United States challenged the safety of vaccines with grotesque cartoons showing children with cows growing out of their heads (the smallpox vaccine was derived from pus taken from cows). It also attacked the laws as a conspiracy between vaccine companies and crooked politicians, and linked opposition to vaccination with the abolition of slavery.

The British Library

An ad from the 1940s in Britain.

Propaganda would play an even more outsized role in World War II. Joseph Goebbels, the Nazi Minister for Popular Enlightenment and Propaganda, raised the art to new and more sinister heights. And health care stayed in propagandists’ sights: Governments on both sides portrayed personal health care as a strike against the real battlefield enemy.

Venereal disease was a big target. During World War I, tens of thousands of soldiers had been knocked out of service each day by gonorrhea and syphilis. When World War II began, government posters gave soldiers explicit post-liaison hygiene instructions (“urinate afterwards”), or reminded GIs that they owed it to their country to stay healthy. One piece of propaganda, from the 1940s, showed a curly-haired harlot, a German tank, and the line, “Gonorrhea and Syphilis Aid the Axis.”

These kinds of appeals to the strength of the nation were common 70 years ago. When pro-government propagandists thought about the attachments that motivate people, they often seized on allegiance to country and obligations to the greater good. In that light, it’s striking that such arguments have been largely absent from the ACA debate. Though widespread participation is crucial to the success of the Affordable Care Act, and national strength is a rationale for a new health care law, pro-ACA propaganda has largely stayed away from “collective interest” kinds of arguments.

“I would have thought there would have been a huge emphasis on national virtues, national strength,” says Welch, describing the arguments he expected to see in pro-ACA propaganda. “It shocked me [Obama] hasn’t been able to do that.”

National Library of Medicine

An American wartime VD campaign.

One reason for the lighter touch, Welch and others say, is that the heavy-handedness of wartime propaganda put Americans permanently on the alert for any hint of old-fashioned government manipulation.

Another may be something many of the 20th century’s leading propagandists recognized: that propaganda only works when it plays to beliefs people already hold. In 1936 Aldous Huxley wrote, “the propagandist is a man that canalises an already existing stream; in a land where there is no water, he digs in vain.”

This gave opponents of the Affordable Care Act an easy tactic: Play on people’s mistrust of government. During World War I, Uncle Sam was a credible figure who could say with a straight face, “I Want You For the U.S. Army.” Today he pops up in anti-ACA propaganda with a deranged look on his face, wielding a speculum.

For President Obama, though, the messaging is trickier. “The Obama administration is sort of hamstrung,” says James Kimble, a professor of communication at Seton Hall University and author of a book on propaganda. “The sorts of appeals that will work for the party faithful are a lot less likely to work for the antagonists, and Obama has a lot of antagonists out there.”

So supporters of the law have tried to downplay its magnitude and any sense of duty to a wider cause. Instead, they’ve appealed to something that, in the modern age of propaganda, has been a staple of everything from AIDS prevention campaigns to Army recruiting ads: individual self-interest. If anything, the government wants to argue, having health insurance will simply let you do more of what you already want to do.

Seventy years ago, the best reason the government could give you to avoid contracting a sexually transmitted disease was to save the world from fascism. Today, with a public whose worst fear is that you’re trying to con them into something against their self-interest, the best reason supporters can give you to sign up for health insurance is that it will...free you to do more keg stands? When propaganda is afraid of looking too much like propaganda, the only effective argument left might be: Look out for yourself.

Kevin Hartnett, an Ideas columnist, is a writer in South Carolina. He can be reached at kshartnett18@gmail.com.